Provider First Line Business Practice Location Address:
69 E FAIRMOUNT AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKEWOOD
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14750-1809
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
814-723-4560
Provider Business Practice Location Address Fax Number:
814-757-5807
Provider Enumeration Date:
12/23/2005